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1.  Adolescent Reasons for Quitting Smoking: Initial Psychometric Evaluation 
Most adolescent smokers report intentions to quit and the majority attempt cessation. Yet, little is known regarding the relationship between adolescent motives for cessation and smoking cessation efforts. To this end, the present study describes an initial evaluation of the psychometric characteristics of the Adolescent Reasons for Quitting scale (ARFQ), a measure of adolescent motives for smoking cessation. Participants were 109 current smoking high school students assessed at baseline and 6-month follow up. The ARFQ item content and format was developed in a separate qualitative study with 36 high school students who had previously attempted to quit smoking. Exploratory factor analyses of ARFQ items yielded three subscales: short-term consequences, social disapproval, and long-term concerns. Validation analyses were conducted in relation to concurrent intentions to stop smoking and prospective smoking cessation attempts, providing evidence of concurrent, predictive and discriminant validity. In particular, the social disapproval and long-term concern subscales significantly predicted subsequent cessation attempts. As such, the ARFQ may prove valuable for informing interventions to encourage adolescent smoking cessation.
doi:10.1037/0893-164X.22.1.129
PMCID: PMC2757254  PMID: 18298239
Adolescent; cessation motives; smoking cessation; psychometric evaluation; prospective study
2.  Effects of motivational interviewing on smoking cessation in adolescents with psychiatric disorders 
Tobacco control  2003;12(Suppl 4):IV3-I10.
Objective
To test the hypothesis that among adolescent smokers hospitalised for psychiatric and substance use disorders, motivational interviewing (MI) would lead to more and longer quit attempts, reduced smoking, and more abstinence from smoking over a 12 month follow up.
Design
Randomised control trial of MI versus brief advice (BA) for smoking cessation, with pre- and post-intervention assessment of self efficacy and intentions to change, and smoking outcome variables assessed at one, three, six, nine, and 12 month follow ups.
Setting
A private, university affiliated psychiatric hospital in Providence, Rhode Island, USA.
Patients or other participants
Consecutive sample (n = 191) of 13–17 year olds, admitted for psychiatric hospitalisation, who smoked at least one cigarette per week for the past four weeks, had access to a telephone, and did not meet DSM-IV criteria for current psychotic disorder.
Interventions
MI versus BA. MI consisted of two, 45 minute individual sessions, while BA consisted of 5–10 minutes of advice and information on how to quit smoking. Eligible participants in both conditions were offered an eight week regimen of transdermal nicotine patch upon hospital discharge.
Main outcome measures
Point prevalence abstinence, quit attempts, changes in smoking rate and longest quit attempt. Proximal outcomes included intent to change smoking behaviour (upon hospital discharge), and self efficacy for smoking cessation.
Results
MI did not lead to better smoking outcomes compared to BA. MI was more effective than BA for increasing self efficacy regarding ability to quit smoking. A significant interaction of treatment with baseline intention to quit smoking was also found. MI was more effective than BA for adolescents with little or no intention to change their smoking, but was actually less effective for adolescents with pre-existing intention to cut down or quit smoking. However, the effects on these variables were relatively modest and only moderately related to outcome. Adolescents with comorbid substance use disorders smoked more during follow up while those with anxiety disorders smoked less and were more likely to be abstinent.
Conclusions
The positive effect of MI on self efficacy for quitting and the increase in intention to change in those with initially low levels of intentions suggest the benefits of such an intervention. However, the effects on these variables were relatively modest and only moderately related to outcome. The lack of overall effect of MI on smoking cessation outcomes suggests the need to further enhance and intensify this type of treatment approach for adolescent smokers with psychiatric comorbidity.
doi:10.1136/tc.12.suppl_4.iv3
PMCID: PMC1766133  PMID: 14645934
3.  Effects of motivational interviewing on smoking cessation in adolescents with psychiatric disorders 
Tobacco Control  2003;12(Suppl 4):iv3-iv10.
Objective:To test the hypothesis that among adolescent smokers hospitalised for psychiatric and substance use disorders, motivational interviewing (MI) would lead to more and longer quit attempts, reduced smoking, and more abstinence from smoking over a 12 month follow up.
Design:Randomised control trial of MI versus brief advice (BA) for smoking cessation, with pre- and post-intervention assessment of self efficacy and intentions to change, and smoking outcome variables assessed at one, three, six, nine, and 12 month follow ups.
Setting:A private, university affiliated psychiatric hospital in Providence, Rhode Island, USA.
Patients or other participants:Consecutive sample (n = 191) of 13–17 year olds, admitted for psychiatric hospitalisation, who smoked at least one cigarette per week for the past four weeks, had access to a telephone, and did not meet DSM-IV criteria for current psychotic disorder.
Interventions:MI versus BA. MI consisted of two, 45 minute individual sessions, while BA consisted of 5–10 minutes of advice and information on how to quit smoking. Eligible participants in both conditions were offered an eight week regimen of transdermal nicotine patch upon hospital discharge.
Main outcome measures:Point prevalence abstinence, quit attempts, changes in smoking rate and longest quit attempt. Proximal outcomes included intent to change smoking behaviour (upon hospital discharge), and self efficacy for smoking cessation.
Results:MI did not lead to better smoking outcomes compared to BA. MI was more effective than BA for increasing self efficacy regarding ability to quit smoking. A significant interaction of treatment with baseline intention to quit smoking was also found. MI was more effective than BA for adolescents with little or no intention to change their smoking, but was actually less effective for adolescents with pre-existing intention to cut down or quit smoking. However, the effects on these variables were relatively modest and only moderately related to outcome. Adolescents with comorbid substance use disorders smoked more during follow up while those with anxiety disorders smoked less and were more likely to be abstinent.
Conclusions:The positive effect of MI on self efficacy for quitting and the increase in intention to change in those with initially low levels of intentions suggest the benefits of such an intervention. However, the effects on these variables were relatively modest and only moderately related to outcome. The lack of overall effect of MI on smoking cessation outcomes suggests the need to further enhance and intensify this type of treatment approach for adolescent smokers with psychiatric comorbidity.
doi:10.1136/tc.12.suppl_4.iv3
PMCID: PMC1766133  PMID: 14645934
4.  Parental Influence on Adolescent Smoking Cessation: Is there a Gender Difference? 
Addictive behaviors  2011;37(2):211-216.
We examined the association of parental disapproval of adolescent smoking and parental smoking status, with past smoking quit behaviors among daily-smoking, high school-aged adolescents, and also tested whether these associations differ for boys and girls. Adolescent regular smokers (N = 253) completed questions on smoking behaviors, past smoking cessation behaviors, parental disapproval of smoking, and parental smoking. Past smoking cessation behaviors were defined as “the number of quit attempts that lasted longer than 24 hours” and “the longest number of days of abstinence”. Logistic regression analyses showed that for all adolescents, even having one smoking parent was associated with decreased odds of being abstinent for longer than 2 days. However, for girls, not having any smoking parents was associated with greater duration of abstinence (> 2 weeks). Having both parents, compared with not having any parents disapprove of smoking, was associated with greater number of quit attempts in boys, but this effect was not found in girls. The results indicate that parents have a salient role in adolescent smoking cessation behaviors, and this association appears to be gender-specific. However, further research is needed to understand the mechanisms that explain gender differences in parental influence on adolescent smoking cessation behaviors.
doi:10.1016/j.addbeh.2011.10.013
PMCID: PMC3236087  PMID: 22070852
adolescents; gender; smoking cessation; parents
5.  Effects of sixty six adolescent tobacco use cessation trials and seventeen prospective studies of self-initiated quitting 
Tobacco Induced Diseases  2002;1(1):35-81.
This paper provides a review of the last two and a half decades of research in adolescent and young-adult tobacco use cessation. A total of 66 tobacco cessation intervention studies – targeted or population – are reviewed. In addition, an exhaustive review is completed of adolescent self-initiated tobacco use cessation, involving 17 prospective survey studies.
Average reach and retention across the intervention studies was 61% and 78%, respectively, and was higher when whole natural units were treated (e.g., classrooms), than when units created specifically for the program were treated (e.g., school-based clinics). The mean quit-rate at a three to 12-month average follow-up among the program conditions was 12%, compared to approximately 7% across control groups. A comparison of intervention theories revealed that motivation enhancement (19%) and contingency-based reinforcement (16%) programs showed higher quit-rates than the overall intervention cessation mean. Regarding modalities (channels) of change, classroom-based programs showed the highest quit rates (17%). Computer-based (expert system) programs also showed promise (13% quit-rate), as did school-based clinics (12%).
There was a fair amount of missing data and wide variation on how data points were measured in the programs' evaluations. Also, there were relatively few direct comparisons of program and control groups. Thus, it would be difficult to conduct a formal meta-analysis on the cessation programs. Still, these data suggest that use of adolescent tobacco use cessation interventions double quit rates on the average.
In the 17 self-initiated quitting survey studies, key predictors of quitting were living in a social milieu that is composed of fewer smokers, less pharmacological or psychological dependence on smoking, anti-tobacco beliefs (e.g., that society should step in to place controls on smoking) and feeling relatively hopeful about life. Key variables relevant to the quitting process may include structuring the context of programming for youth, motivating quit attempts and reducing ambivalence about quitting, and making programming enjoyable as possible. There also is a need to help youth to sustain a quit-attempt. In this regard, one could provide ongoing support during the acute withdrawal period and teach youth social/life skills. Since there is little information currently available on use of nicotine replacement in young people, continued research in this arena might also be a useful focus for future work.
doi:10.1186/1617-9625-1-1-35
PMCID: PMC2671530  PMID: 19570247
6.  Effects of sixty six adolescent tobacco use cessation trials and seventeen prospective studies of self-initiated quitting 
This paper provides a review of the last two and a half decades of research in adolescent and young-adult tobacco use cessation. A total of 66 tobacco cessation intervention studies – targeted or population – are reviewed. In addition, an exhaustive review is completed of adolescent self-initiated tobacco use cessation, involving 17 prospective survey studies.
Average reach and retention across the intervention studies was 61% and 78%, respectively, and was higher when whole natural units were treated (e.g., classrooms), than when units created specifically for the program were treated (e.g., school-based clinics). The mean quit-rate at a three to 12-month average follow-up among the program conditions was 12%, compared to approximately 7% across control groups. A comparison of intervention theories revealed that motivation enhancement (19%) and contingency-based reinforcement (16%) programs showed higher quit-rates than the overall intervention cessation mean. Regarding modalities (channels) of change, classroom-based programs showed the highest quit rates (17%). Computer-based (expert system) programs also showed promise (13% quit-rate), as did school-based clinics (12%).
There was a fair amount of missing data and wide variation on how data points were measured in the programs' evaluations. Also, there were relatively few direct comparisons of program and control groups. Thus, it would be difficult to conduct a formal meta-analysis on the cessation programs. Still, these data suggest that use of adolescent tobacco use cessation interventions double quit rates on the average.
In the 17 self-initiated quitting survey studies, key predictors of quitting were living in a social milieu that is composed of fewer smokers, less pharmacological or psychological dependence on smoking, anti-tobacco beliefs (e.g., that society should step in to place controls on smoking) and feeling relatively hopeful about life. Key variables relevant to the quitting process may include structuring the context of programming for youth, motivating quit attempts and reducing ambivalence about quitting, and making programming enjoyable as possible. There also is a need to help youth to sustain a quit-attempt. In this regard, one could provide ongoing support during the acute withdrawal period and teach youth social/life skills. Since there is little information currently available on use of nicotine replacement in young people, continued research in this arena might also be a useful focus for future work.
doi:10.1186/1617-9625-1-5
PMCID: PMC2669565
7.  Prospective predictors of quitting behaviours among adult smokers in six cities in China: Findings from the International Tobacco Control (ITC) China Survey 
Addiction (Abingdon, England)  2011;106(7):1335-1345.
Aims
To examine predictors of quitting behaviours among adult smokers in China, in light of existing knowledge from previous research in four western countries and two southeast Asian countries.
Design
Face-to-face interviews were carried out with smokers in 2006 using the International Tobacco Control (ITC) China Survey, with follow-up about 16 months later. A stratified multi-stage cluster sampling design was employed.
Setting
Beijing and other five cities in China.
Participants
A total of 4732 smokers were first surveyed in 2006. Of these, 3863 were recontacted in 2007, with a retention rate of 81.6%.
Measurements
Baseline measures of sociodemographics, dependence and interest in quitting were used prospectively to predict both making quit attempts and staying quit among those who attempted.
Findings
Overall, 25.3% Chinese smokers reported having made at least one quit attempt between Waves 1 and 2; of these, 21.7% were still stopped at Wave 2. Independent predictors of making quit attempts included having higher quitting self-efficacy, previous quit attempts, more immediate intentions to quit, longer time to first cigarette upon waking, negative opinion of smoking and having smoking restrictions at home. Independent predictors of staying quit were being older, having longer previous abstinence from smoking, and having more immediate quitting intentions.
Conclusions
Predictors of Chinese smokers’ quitting behaviours are somewhat different to those found in previous research from other countries. Nicotine dependence and self-efficacy seem to be more important for attempts than for staying quit in China, and quitting intentions are related to both attempts and staying quit.
doi:10.1111/j.1360-0443.2011.03444.x
PMCID: PMC3107915  PMID: 21438942
8.  Association of post-treatment smoking change with future smoking and cessation efforts among adolescents with psychiatric comorbidity 
Little is known about how initial change following a smoking intervention relates to longer-term smoking outcomes among adolescent smokers with psychiatric comorbidity. The present study investigated this relationship among psychiatrically hospitalized adolescents (N=183) who participated in a controlled trial comparing motivational interviewing to brief advice. Quit attempters (n=37), reducers (n=45), and maintainers (n=101) were assembled based on, respectively, having made a quit attempt, having reduced smoking by at least 50%, and having reduced smoking by less than 50% in the first week after hospital discharge. Hierarchical linear models and generalized estimating equations were conducted to test group differences in average number of cigarettes per smoking day and odds of making a quit attempt during subsequent weeks of a 12-month continuous follow-up, and in cotinine-verified abstinence rates at 1, 6, and 12 months posthospitalization. Baseline smoking levels and presence of a substance use disorder or anxiety disorder were predictive of outcomes. After controlling for covariates, we found that quit attempters smoked less during follow-up than did the other change groups and that reducers smoked less than maintainers. Quit attempters evidenced a higher percentage of quit attempts during follow-up than did the other change groups. Reducers had a greater average percentage of quit attempts during follow-up than did maintainers. However, groups did not differ on cotinine-verified abstinence rates across the follow-up period. Findings have implications for initial post-treatment change as it relates to subsequent smoking and cessation outcomes among adolescent smokers at especially high risk for smoking persistence.
doi:10.1080/14622200701651734
PMCID: PMC2866127  PMID: 18058348
9.  Physician Communication Regarding Smoking and Adolescent Tobacco Use 
Pediatrics  2011;127(6):e1368-e1374.
BACKGROUND:
Physician advice increases quit rates 1% to 3% above unassisted quit rates among adults, an increase sufficient to be ranked as a high-priority, evidence-based preventive service. However, there is little research on the potential impact of physician advice on adolescent smoking.
OBJECTIVE:
The purpose of this study was to examine the association between recalled physician communication and adolescents' attitudes toward smoking, knowledge about smoking, intentions to smoke, tobacco use, and quitting behaviors.
METHODS:
This study was a retrospective observational study of 5154 students (82.9% black, 17.1% white) from an urban, mid-South school system. Outcome variables included adolescents' self-rated attitudes toward smoking, knowledge about smoking, intentions to smoke, tobacco use, and quitting behaviors.
RESULTS:
Physician advice and the combination of screening and advice were associated with healthier attitudes about smoking. Physician screening and advice were also associated with a more accurate knowledge regarding tobacco-related damage. Among current smokers, recalled physician advice was also associated with reduced intentions to smoke in 5 years. Importantly, advised teens were more likely to plan to quit smoking in 6 months. Furthermore, teens who were screened by their physician reported significantly more quit attempts than those who were neither screened nor advised (P = .007).
CONCLUSIONS:
Physician's tobacco-related interactions with adolescents seemed to positively impact their attitudes, knowledge, intentions to smoke, and quitting behaviors. Brief physician interventions have the potential to be a key intervention on a public health level through the prevention, cessation, and reduction of smoking and smoking-related disease.
doi:10.1542/peds.2010-1195
PMCID: PMC3103271  PMID: 21576307
smoking; adolescent; counseling; physician's role
10.  Intentions to quit smoking among youth in substance abuse treatment 
Drug and alcohol dependence  2009;106(1):48.
Introduction:
Smoking cessation interventions for adolescents in substance abuse treatment have shown promise. However, a better understanding of the correlates of substance use disordered (SUD) youths' intentions toward smoking cessation will help tailor cessation interventions to this population. The current study examined tobacco use, smoking-related self-efficacy, substance use and intentions to quit using alcohol and illicit drugs as correlates of intentions to quit smoking among youth in SUD treatment.
Methods:
Participants were 178 adolescents who were in inpatient (n=90) or outpatient (n= 88) SUD treatment and had smoked at least once in the past 30 days. The sample was 44% female, 72% non-Hispanic Caucasian, with a mean age of 16.2 years (SD=1.2). Participants rated the likelihood that they would be nonsmokers in the next year (9-point scale).
Results:
SUD youth intention to quit smoking averaged 4.9 out of 10 (SD=3.2), comparable to intention to quit drinking (M=5.3, SD=3.6), but lower than their intention to quit using drugs (M=6.0, SD=3.4). Teens' intentions to quit smoking were associated with nicotine dependence (r=−.30, p<.01) and smoking-cessation related self-efficacy (r=.36, p<.01), but not with pretreatment substance use severity (r=−.15). Controlling for nicotine dependence, teens' intentions to quit smoking were positively related to smoking cessation self-efficacy (pr=.26, p<.01) and intention to quit using illicit drugs (pr=.15, p<.05), but unrelated to intention to quit drinking.
Discussion:
Findings highlight the appropriateness of addressing adolescent tobacco use during SUD treatment, but emphasize the importance of assessing intention and other cognitions for each substance, as they may differ markedly.
doi:10.1016/j.drugalcdep.2009.07.004
PMCID: PMC2815104  PMID: 19699041
Youth tobacco use; Substance use; Comorbidity
11.  Smoking Cessation for Patients With Chronic Obstructive Pulmonary Disease (COPD) 
Executive Summary
In July 2010, the Medical Advisory Secretariat (MAS) began work on a Chronic Obstructive Pulmonary Disease (COPD) evidentiary framework, an evidence-based review of the literature surrounding treatment strategies for patients with COPD. This project emerged from a request by the Health System Strategy Division of the Ministry of Health and Long-Term Care that MAS provide them with an evidentiary platform on the effectiveness and cost-effectiveness of COPD interventions.
After an initial review of health technology assessments and systematic reviews of COPD literature, and consultation with experts, MAS identified the following topics for analysis: vaccinations (influenza and pneumococcal), smoking cessation, multidisciplinary care, pulmonary rehabilitation, long-term oxygen therapy, noninvasive positive pressure ventilation for acute and chronic respiratory failure, hospital-at-home for acute exacerbations of COPD, and telehealth (including telemonitoring and telephone support). Evidence-based analyses were prepared for each of these topics. For each technology, an economic analysis was also completed where appropriate. In addition, a review of the qualitative literature on patient, caregiver, and provider perspectives on living and dying with COPD was conducted, as were reviews of the qualitative literature on each of the technologies included in these analyses.
The Chronic Obstructive Pulmonary Disease Mega-Analysis series is made up of the following reports, which can be publicly accessed at the MAS website at: http://www.hqontario.ca/en/mas/mas_ohtas_mn.html.
Chronic Obstructive Pulmonary Disease (COPD) Evidentiary Framework
Influenza and Pneumococcal Vaccinations for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Smoking Cessation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Community-Based Multidisciplinary Care for Patients With Stable Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Pulmonary Rehabilitation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Long-term Oxygen Therapy for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Noninvasive Positive Pressure Ventilation for Acute Respiratory Failure Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Noninvasive Positive Pressure Ventilation for Chronic Respiratory Failure Patients With Stable Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Hospital-at-Home Programs for Patients With Acute Exacerbations of Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Home Telehealth for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Cost-Effectiveness of Interventions for Chronic Obstructive Pulmonary Disease Using an Ontario Policy Model
Experiences of Living and Dying With COPD: A Systematic Review and Synthesis of the Qualitative Empirical Literature
For more information on the qualitative review, please contact Mita Giacomini at: http://fhs.mcmaster.ca/ceb/faculty member_giacomini.htm.
For more information on the economic analysis, please visit the PATH website: http://www.path-hta.ca/About-Us/Contact-Us.aspx.
The Toronto Health Economics and Technology Assessment (THETA) collaborative has produced an associated report on patient preference for mechanical ventilation. For more information, please visit the THETA website: http://theta.utoronto.ca/static/contact.
Objective
The objective of this evidence-based analysis was to determine the effectiveness and cost-effectiveness of smoking cessation interventions in the management of chronic obstructive pulmonary disease (COPD).
Clinical Need: Condition and Target Population
Tobacco smoking is the main risk factor for COPD. It is estimated that 50% of older smokers develop COPD and more than 80% of COPD-associated morbidity is attributed to tobacco smoking. According to the Canadian Community Health Survey, 38.5% of Ontarians who smoke have COPD. In patients with a significant history of smoking, COPD is usually present with symptoms of progressive dyspnea (shortness of breath), cough, and sputum production. Patients with COPD who smoke have a particularly high level of nicotine dependence, and about 30.4% to 43% of patients with moderate to severe COPD continue to smoke. Despite the severe symptoms that COPD patients suffer, the majority of patients with COPD are unable to quit smoking on their own; each year only about 1% of smokers succeed in quitting on their own initiative.
Technology
Smoking cessation is the process of discontinuing the practice of inhaling a smoked substance. Smoking cessation can help to slow or halt the progression of COPD. Smoking cessation programs mainly target tobacco smoking, but may also encompass other substances that can be difficult to stop smoking due to the development of strong physical addictions or psychological dependencies resulting from their habitual use.
Smoking cessation strategies include both pharmacological and nonpharmacological (behavioural or psychosocial) approaches. The basic components of smoking cessation interventions include simple advice, written self-help materials, individual and group behavioural support, telephone quit lines, nicotine replacement therapy (NRT), and antidepressants. As nicotine addiction is a chronic, relapsing condition that usually requires several attempts to overcome, cessation support is often tailored to individual needs, while recognizing that in general, the more intensive the support, the greater the chance of success. Success at quitting smoking decreases in relation to:
a lack of motivation to quit,
a history of smoking more than a pack of cigarettes a day for more than 10 years,
a lack of social support, such as from family and friends, and
the presence of mental health disorders (such as depression).
Research Question
What are the effectiveness and cost-effectiveness of smoking cessation interventions compared with usual care for patients with COPD?
Research Methods
Literature Search
Search Strategy
A literature search was performed on June 24, 2010 using OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations (1950 to June Week 3 2010), EMBASE (1980 to 2010 Week 24), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Cochrane Library, and the Centre for Reviews and Dissemination for studies published between 1950 and June 2010. A single reviewer reviewed the abstracts and obtained full-text articles for those studies meeting the eligibility criteria. Reference lists were also examined for any additional relevant studies not identified through the search. Data were extracted using a standardized data abstraction form.
Inclusion Criteria
English-language, full reports from 1950 to week 3 of June, 2010;
either randomized controlled trials (RCTs), systematic reviews and meta-analyses, or non-RCTs with controls;
a proven diagnosis of COPD;
adult patients (≥ 18 years);
a smoking cessation intervention that comprised at least one of the treatment arms;
≥ 6 months’ abstinence as an outcome; and
patients followed for ≥ 6 months.
Exclusion Criteria
case reports
case series
Outcomes of Interest
≥ 6 months’ abstinence
Quality of Evidence
The quality of each included study was assessed taking into consideration allocation concealment, randomization, blinding, power/sample size, withdrawals/dropouts, and intention-to-treat analyses.
The quality of the body of evidence was assessed as high, moderate, low, or very low according to the GRADE Working Group criteria. The following definitions of quality were used in grading the quality of the evidence:
Summary of Findings
Nine RCTs were identified from the literature search. The sample sizes ranged from 74 to 5,887 participants. A total of 8,291 participants were included in the nine studies. The mean age of the patients in the studies ranged from 54 to 64 years. The majority of studies used the Global Initiative for Chronic Obstructive Lung Disease (GOLD) COPD staging criteria to stage the disease in study subjects. Studies included patients with mild COPD (2 studies), mild-moderate COPD (3 studies), moderate–severe COPD (1 study) and severe–very severe COPD (1 study). One study included persons at risk of COPD in addition to those with mild, moderate, or severe COPD, and 1 study did not define the stages of COPD. The individual quality of the studies was high. Smoking cessation interventions varied across studies and included counselling or pharmacotherapy or a combination of both. Two studies were delivered in a hospital setting, whereas the remaining 7 studies were delivered in an outpatient setting. All studies reported a usual care group or a placebo-controlled group (for the drug-only trials). The follow-up periods ranged from 6 months to 5 years. Due to excessive clinical heterogeneity in the interventions, studies were first grouped into categories of similar interventions; statistical pooling was subsequently performed, where appropriate. When possible, pooled estimates using relative risks for abstinence rates with 95% confidence intervals were calculated. The remaining studies were reported separately.
Abstinence Rates
Table ES1 provides a summary of the pooled estimates for abstinence, at longest follow-up, from the trials included in this review. It also shows the respective GRADE qualities of evidence.
Summary of Results*
Abbreviations: CI, confidence interval; NRT, nicotine replacement therapy.
Statistically significant (P < 0.05).
One trial used in this comparison had 2 treatment arms each examining a different antidepressant.
Conclusions
Based on a moderate quality of evidence, compared with usual care, abstinence rates are significantly higher in COPD patients receiving intensive counselling or a combination of intensive counselling and NRT.
Based on limited and moderate quality of evidence, abstinence rates are significantly higher in COPD patients receiving NRT compared with placebo.
Based on a moderate quality of evidence, abstinence rates are significantly higher in COPD patients receiving the antidepressant bupropion compared to placebo.
PMCID: PMC3384371  PMID: 23074432
12.  Predictors of smoking cessation among adult smokers in Malaysia and Thailand: Findings from the International Tobacco Control Southeast Asia Survey 
Nicotine & Tobacco Research  2010;12(Suppl 1):S34-S44.
Introduction:
Limited longitudinal studies on smoking cessation have been reported in Asia, and it remains unclear whether determinants of quitting are similar to those found in Western countries. This study examined prospective predictors of smoking cessation among adult smokers in Thailand and Malaysia.
Methods:
Four thousand and four smokers were surveyed in Malaysia and Thailand in 2005. Of these, 2,426 smokers were followed up in 2006 (61% retention). Baseline measures of sociodemographics, dependence, and interest in quitting were used to predict both making quit attempts and point prevalence maintenance of cessation.
Results:
More Thai than Malaysian smokers reported having made quit attempts between waves, but among those who tried, the rates of staying quit were not considerably different between Malaysians and Thais. Multivariate analyses showed that smoking fewer cigarettes per day, higher levels of self-efficacy, and more immediate quitting intentions were predictive of both making a quit attempt and staying quit in both countries. Previous shorter quit attempts and higher health concerns about smoking were only predictive of making an attempt, whereas prior abstinence for 6 months or more and older age were associated with maintenance.
Discussion:
In Malaysia and Thailand, predictors of quitting activity appear to be similar. However, as in the West, predictors of making quit attempts are not all the same as those who predict maintenance. The actual predictors differ in potentially important ways from those found in the West. We need to determine the relative contributions of cultural factors and the shorter history of efforts to encourage quitting in Asia.
doi:10.1093/ntr/ntq030
PMCID: PMC2948135  PMID: 20889478
13.  Normative influences on intentions to smoke among Greek adolescents: the moderating role of smoking status 
Tobacco Induced Diseases  2014;12(1):5.
Background
Social norms influence adolescent smoking intentions, but this effect may differentiate depending on current smoking experiences. The presented study assessed the moderation effects of smoking status on the relationship between social norms and smoking intentions among Greek adolescents.
Methods
A cross-section survey-based design was used. Overall, 251 Greek secondary school students (M age = 16.1 years, 61.2% females) completed structured and anonymous questionnaires including demographic characteristics (age, gender), subjective and descriptive social norms towards smoking, self-reported tobacco use, and intentions to smoke in the next 12 months.
Results
Linear regression analysis showed that social norms overall predicted 36.4% (Adjusted R2) of the variance in intentions. Perceived prevalence of smoking in same age peers and adults, having more close friends who smoke and perceived social approval of smoking predicted intentions to smoke in one year. Moderated regression analysis showed that the effects of social norms on smoking intentions were significantly moderated by smoking status.
Conclusions
Social norms predict smoking intentions, but this effect is stronger among ever (than never) smoker adolescents. Adolescents with smoking experiences may selectively attend to pro-smoking social cues and this perpetuates into their motivation to keep up the habit. School-based interventions should target normative beliefs and related cognitive processes, especially among adolescents who have already initiated tobacco use.
doi:10.1186/1617-9625-12-5
PMCID: PMC3973024  PMID: 24670201
Adolescents; Social norms; Smoking intentions
14.  A Brief Motivational Interview in a Pediatric Emergency Department, Plus 10-Day Telephone Follow-Up, Increases Attempts to Quit Drinking Among Youth and Young Adults Who Screen Positive for Problematic Drinking 
Objectives
Adolescents in their late teens and early twenties have the highest alcohol consumption in the United States; binge drinking peaks at age 21 years. Underage drinking is associated with many negative consequences, including academic problems and risk of intentional and unintentional injuries. This study tested the effectiveness of pediatric emergency department (PED) screening and brief intervention to reduce alcohol consumption and associated risks.
Methods
A three-group randomized assignment trial was structured to test differences between intervention (I) and standard assessed control (AC) groups in alcohol consumption and alcohol-related behaviors from baseline to 12 months, and to compare the AC group with a minimally assessed control group (MAC) to adjust for the effect of assessment reactivity on control group behavior. Patients aged 14–21 years were eligible if they screened positive on the Alcohol Use Disorders Identification Test (AUDIT), or for binge drinking or high-risk behaviors. The MAC group received a resource handout, written advice about alcohol-related risks, and a 12-month follow-up appointment. Patients in the AC group were assessed using standardized instruments in addition to the MAC protocol. The intervention group received a peer-conducted motivational intervention, erral to community resources and treatment if indicated, and a ten-day booster in addition to assessment. Measurements included 30 day self-report of alcohol consumption and alcohol-related behaviors, screens for depression and posttraumatic stress disorder, and self-report of attempts to quit, cut back, or change conditions of use, all repeated at follow-up. Motor vehicle records and medical records were also analyzed for changes from baseline to one year follow-up.
Results
Among 7,807 PED patients screened, 1,202 were eligible; 853 enrolled (I n = 283; AC n = 284; MAC n = 286), with a 12-month follow-up rate of 72%. At 12 months, more than half of enrollees in RAP (Reaching Adolescents for Prevention) attempted to cut back on drinking, and over a third tried to quit. A significantly larger proportion of the I group made efforts to quit drinking and to be careful about situations when drinking compared to AC enrollees, and there was a numerically but not significantly greater likelihood (p = 0.065) among the I group for efforts to cut back on drinking. At three months, the likelihood of the I group making attempts to cut back was almost triple that of ACs. For efforts to quit, it was double, and for trying to be careful about situations when drinking, there was a 72% increase in the odds ratio for the I group. Three-month results for attempts were sustained at 12 months for quit attempts and efforts to be careful. Consumption declined in both groups from baseline to 3 months to 12 months, but there were no significant between-group differences in alcohol-related consequences at 12 months, or in alcohol-related risk behaviors. We found a pattern suggestive of assessment reactivity in only one variable at 12 months: the attempt to cut back (73.3% for the I group vs. 64.9% among the AC group, and 54.8% among the MAC group).
Conclusions
Brief motivational intervention resulted in significant efforts to change behavior (quit drinking and be careful about situations while drinking) but did not alter between-group consumption or consequences.
doi:10.1111/j.1553-2712.2010.00818.x
PMCID: PMC2913305  PMID: 20670329
youth drinking; brief intervention; SBIRT; motivational interviewing; alcohol consequences
15.  Parent smoker role conflict and planning to quit smoking: a cross-sectional study 
BMC Public Health  2013;13:164.
Background
Role conflict can motivate behavior change. No prior studies have explored the association between parent/smoker role conflict and readiness to quit. The objective of the study is to assess the association of a measure of parent/smoker role conflict with other parent and child characteristics and to test the hypothesis that parent/smoker role conflict is associated with a parent’s intention to quit smoking in the next 30 days. As part of a cluster randomized controlled trial to address parental smoking (Clinical Effort Against Secondhand Smoke Exposure—CEASE), research assistants completed exit interviews with 1980 parents whose children had been seen in 20 Pediatric Research in Office Settings (PROS) practices and asked a novel identity-conflict question about “how strongly you agree or disagree” with the statement, “My being a smoker gets in the way of my being a parent.” Response choices were dichotomized as “Strongly Agree” or “Agree” versus “Disagree” or “Strongly Disagree” for the analysis. Parents were also asked whether they were “seriously planning to quit smoking in 30 days.” Chi-square and logistic regression were performed to assess the association between role conflict and other parent/children characteristics. A similar strategy was used to determine whether role conflict was independently associated with intention to quit in the next 30 days.
Methods
As part of a RTC in 20 pediatric practices, exit interviews were held with smoking parents after their child’s exam. Parents who smoked were asked questions about smoking behavior, smoke-free home and car rules, and role conflict. Role conflict was assessed with the question, “Please tell me how strongly you agree or disagree with the statement: ‘My being a smoker gets in the way of my being a parent.’ (Answer choices were: “Strongly agree, Agree, Disagree, Strongly Disagree.”)
Results
Of 1980 eligible smokers identified, 1935 (97%) responded to the role-conflict question, and of those, 563 (29%) reported experiencing conflict. Factors that were significantly associated with parent/smoker role conflict in the multivariable model included: being non-Hispanic white, allowing home smoking, the child being seen that day for a sick visit, parents receiving any assistance for their smoking, and planning to quit in the next 30 days. In a separate multivariable logistic regression model, parent/smoker role conflict was independently associated with intention to quit in the next 30 days [AOR 2.25 (95% CI 1.80-2.18)].
Conclusion
This study demonstrated an association between parent/smoker role conflict and readiness to quit. Interventions that increase parent/smoker role conflict might act to increase readiness to quit among parents who smoke.
Trial registration
Clinical trial registration number: NCT00664261.
doi:10.1186/1471-2458-13-164
PMCID: PMC3600049  PMID: 23433098
Parent smoker identity; Parent smoker role conflict; Tobacco smoke exposure; Readiness to quit; Stages of change; Tobacco control; Pediatrics; Smoking cessation; Parent child dyad
16.  Developing cessation interventions for the social and community service setting: A qualitative study of barriers to quitting among disadvantaged Australian smokers 
BMC Public Health  2011;11:493.
Background
Smoking rates remain unacceptably high among individuals who are socially disadvantaged. Social and community service organisations (SCSO) are increasingly interested in providing smoking cessation support to clients, however little is known about the best way to assist disadvantaged smokers to quit in this setting. This study aimed to explore barriers and facilitators to quitting within the conceptual framework of the PRECEDE model to identify possible interventions appropriate to the social and community service setting.
Methods
Semi-structured focus groups were conducted with clients attending five community welfare organisations located in New South Wales, Australia. Thirty-two clients participated in six focus groups. A discussion guide was used to explore the barriers and facilitators to smoking and smoking cessation including: current smoking behaviour, motivation to quit, past quit attempts, barriers to quitting and preferences for cessation support. Focus groups were audio-taped, transcribed and analysed using thematic analysis techniques.
Results
Participants were current smokers and most expressed a desire to quit. Factors predisposing continued smoking included perceived benefits of smoking for stress relief, doubting of ability to quit, fear of gaining weight, and poor knowledge and scepticism about available quit support. The high cost of nicotine replacement therapy was a barrier to its use. Continual exposure to smoking in personal relationships and in the community reinforced smoking. Participants expressed a strong preference for personalised quit support.
Conclusions
Disadvantaged smokers in Australia express a desire to quit smoking, but find quitting difficult for a number of reasons. SCSOs may have a role in providing information about the availability of quit support, engaging disadvantaged smokers with available quit support, and providing personalised, ongoing support.
doi:10.1186/1471-2458-11-493
PMCID: PMC3135539  PMID: 21699730
Smoking; Vulnerable Populations; Inequalities; PRECEDE-PROCEED model
17.  Smokers living in deprived areas are less likely to quit: a longitudinal follow‐up 
Tobacco Control  2006;15(6):485-488.
Objective
To follow up smokers to examine whether the likelihood of quitting smoking varied by area deprivation, and whether smoking history, health status, personality characteristics, social support and stressful situations contributed to differences in area deprivation in quit rates.
Design
Longitudinal data with a 6‐year follow‐up period were analysed using multilevel logistic regression. Area‐level deprivation was characterised by a composite measure that was the sum of the proportion of unemployed residents, the percentage of residents in blue‐collar occupations and the proportion with only elementary‐level education. Previously established predictors of smoking cessation, including education, age at smoking initiation, self‐assessed health, chronic illness, locus of control, neuroticism, negative life events, longlasting relationship difficulties, emotional social support and negative neighbourhood conditions were examined separately and in a combined model to assess whether they contributed to neighbourhood deprivation differences in quitting.
Participants
404 participants (residing in 83 areas) identified as smokers at baseline and who did not change their residential address over the follow‐up period.
Main outcome
Being a non‐smoker at follow‐up.
Results
Odds ratios of quitting decreased with greater area‐level deprivation, but differences reached significance only between the most and least deprived quartiles. Smoking history, health status, personality characteristics, social support and stressful situations did not contribute to the lower quitting rates seen among smokers in deprived areas.
Conclusions
Living in a deprived area seems to reduce the likelihood of quitting smoking; hence individual‐level tobacco control efforts should be complemented with area‐based interventions. However, we need to identify and understand the underlying factors associated with living in a deprived area that contributes to lower quitting rates.
doi:10.1136/tc.2006.015750
PMCID: PMC2563671  PMID: 17130379
18.  Pathways of Change Explaining the Effect of Smoke-Free Legislation on Smoking Cessation in the Netherlands. An Application of the International Tobacco Control Conceptual Model 
Nicotine & Tobacco Research  2012;14(12):1474-1482.
Introduction:
This study aims to test the pathways of change from individual exposure to smoke-free legislation on smoking cessation, as hypothesized in the International Tobacco Control (ITC) Conceptual Model.
Methods:
A nationally representative sample of Dutch smokers aged 15 years and older was surveyed during 4 consecutive annual surveys. Of the 1,820 baseline smokers, 1,012 participated in the fourth survey. Structural Equation Modeling was employed to test a model of the effects of individual exposure to smoke-free legislation through policy-specific variables (support for smoke-free legislation and awareness of the harm of [secondhand] smoking) and psychosocial mediators (attitudes, subjective norm, self-efficacy, and intention to quit) on quit attempts and quit success.
Results:
The effect of individual exposure to smoke-free legislation on smoking cessation was mediated by 1 pathway via support for smoke-free legislation, attitudes about quitting, and intention to quit smoking. Exposure to smoke-free legislation also influenced awareness of the harm of (secondhand) smoking, which in turn influenced the subjective norm about quitting. However, only attitudes about quitting were significantly associated with intention to quit smoking, whereas subjective norm and self-efficacy for quitting were not. Intention to quit predicted quit attempts and quit success, and self-efficacy for quitting predicted quit success.
Conclusions:
Our findings support the ITC Conceptual Model, which hypothesized that policies influence smoking cessation through policy-specific variables and psychosocial mediators. Smoke-free legislation may increase smoking cessation, provided that it succeeds in influencing support for the legislation.
doi:10.1093/ntr/nts081
PMCID: PMC3509014  PMID: 22491892
19.  Patterns of motivations and ways of quitting smoking among Polish smokers: A questionnaire study 
BMC Public Health  2008;8:274.
Background
The majority of Polish smokers declare their will to quit smoking and many of them attempt to quit. Although morbidity and mortality from tobacco-related diseases are among the highest in the world, there is a lack of comprehensive cessation support for smokers. We aimed to investigate how Poles, including the medically ill, cope with quitting cigarettes and what their motivations to quit are.
Methods
Convenience sampling was used for the purpose of the study. Individuals attending several health care units were screened for a history of quit attempts. Ex-smokers were defined as smoking previously at least one cigarette/day but who have no longer been smoking for at least one month. Attempts at quitting were defined as abstaining from cigarettes for at least one day. Data on socio-demographics, tobacco use, quitting behaviors and reasons to quit from 618 subjects (385 ex- and 233 current smokers) who fulfilled these criteria were collected with the use of a questionnaire. For the comparison of proportions, a chi-square test was used.
Results
In the entire study population, 77% of smokers attempted to quit smoking on their own and a similar proportion of smokers (76%) used the cold turkey method when quitting. Current smokers were more likely than former smokers to use some form of aid (p = 0.0001), mainly nicotine replacement therapy (68%). The most important reasons for quitting smoking were: general health concern (57%), personal health problems (32%) and social reasons (32%). However, 41% of smokers prompted to quitting by personal health problems related to tobacco smoking did not see the link between the two. A small proportion of ex-smokers (3%) abstaining from cigarettes for longer than a year were not confident about their self-efficacy to sustain abstinence further.
Conclusion
The majority of Polish smokers, including patients with tobacco-related diseases, attempt to quit without smoking cessation assistance, thus there is a need for a broader professional help for them. There is also a lack of general information on hazards related to tobacco and further anti-tobacco campaigns in media are needed. Finally, former smokers should be given more attention and periodic inquiries regarding the smoking habit are worthwhile.
doi:10.1186/1471-2458-8-274
PMCID: PMC2519083  PMID: 18680600
20.  FACTORS ASSOCIATED WITH TOBACCO SMOKING AND THE BELIEF ABOUT WEIGHT CONTROL EFFECT OF SMOKING AMONG HUNGARIAN ADOLESCENTS 
SUMMARY
Introduction
The relationship between body weight and smoking has been well-documented among adult populations, but the data among youth are inconsistent. This study explores the relationship among social, behavioural, body weight-related factors and adolescent smoking while identifying factors associated with the belief that smoking controls weight.
Materials and methods
Baseline data from a three-year, prospective cohort study started in 2009 in Hungary’s six metropolitan cities. Randomly selected 6th and 9th grade students completed a self-administered questionnaire during the 2009–2010 school year (n=1445; 45% boys, mean age of 6th graders: 12.06 years, SD=0.63; mean age of 9th graders: 15.06 years, SD=0.63). Calculations of Body Mass Index (BMI) were based on objectively measured weight and height data of participants. Appetite-Weight Control Scale of the Short Form of Smoking Consequences Questionnaire was used to measure the belief that smoking supports weight control. Bivariate and multivariate logistic regression analyses were performed to examine the association between the perception of weight control and smoking, while controlling for potential confounding variables (e.g., gender).
Results
24.8% of participants smoked cigarettes within the past 30 days. The odds of smoking were increased among students who were older, had smoking friends, were exposed to parental smoking, and had poorer academic performance. BMI showed positive association with smoking (increases in BMI were associated with higher odds of smoking), and the belief that smoking controls weight mediated this association. There was no difference in smoking prevalence among those motivated either to lose or gain weight (~30%), but was considerably lower among adolescents satisfied with their body weight (19%). The belief that smoking supports weight control was more common for girls, older students, and those who perceived themselves as overweight.
Conclusions
Dissatisfaction with body weight and the belief that smoking has weight controlling effects are associated with an increased likelihood of adolescent smoking, therefore they must be considered in smoking prevention programmes among youth.
PMCID: PMC3821967  PMID: 22571010
smoking; adolescence; weight control belief; BMI; perceived body shape
21.  Harm reduction and cessation efforts and interest in cessation resources among survivors of smoking-related cancers 
Purpose
Despite the well-established risks associated with persistent smoking, many cancer survivors who were active smokers at the time of cancer diagnosis continue to smoke. In order to guide the development of tobacco cessation interventions for cancer survivors, a better understanding is needed regarding post-diagnosis quitting efforts. Thus, we examined quitting and reduction efforts and interest in cessation resources among cancer survivors who self-identified as current smokers at the time of diagnosis.
Methods
We conducted analyses of survey participants (n=54) who were current smokers at the time of cancer diagnosis and were continued smokers at the time of assessment. We also conducted semi-structured interviews (n=21) among a subset of those who either continued to smoke or quit smoking post cancer diagnosis.
Results
Among our survey participants, 22.2% had ever used behavioral cessation resources and 66.7% had use pharmacotherapy, while 62.8% had interest in future use of behavioral cessation resources and 75.0% had interest in pharmacotherapy. The majority reported some quitting efforts including making quit attempts, using cessation medications, and reducing their daily cigarette consumption. Semi-structured interview data revealed various strategies used to aid in smoking reduction and cessation as well as variability in preferences for cessation resources.
Conclusions
Cancer patients who smoke following diagnosis often engage in smoking reduction and cessation-related behaviors, which may reflect their motivation to reduce their smoking-related risks. They also report high interest in cessation resources. Thus, it is important to explore the acceptability and effectiveness of different cessation intervention components among this group.
doi:10.1007/s11764-012-0243-9
PMCID: PMC3568241  PMID: 23307036
Smoking; smoking cessation; survivors; cancer; oncology
22.  Gender differences in cigarette smoking, social correlates and cessation among adolescents 
Addictive Behaviors  2012;37(6):739-742.
Background
Despite well-established gender differences in adult smoking behaviors, relatively little is known about gender discrepancies in smoking behaviors among adolescents, and even less is known about the role of gender in smoking cessation among teen populations.
Method
The present study examined gender differences in a population of 755 adolescents seeking to quit smoking through the American Lung Association’s Not-On-Tobacco (N-O-T) program. All participants enrolled in the N-O-T program between 1998 and 2009. All participants completed a series of questionnaires prior to and immediately following the cessation intervention. Analyses examined gender differences in a range of smoking variables, cessation success and direct and indirect effects on changes in smoking behaviors.
Results
Females were more likely to have a parents, siblings and romantic partners who smokes, perceive those around them will support a cessation effort, smoke more prior to intervention if they have friends who smoke, and to have lower cessation motivation and confidence if they have a parent who smokes. Conversely, males were more likely to have lower cessation motivation and confidence and be less likely to quit if they have a friend who smokes.
Conclusions
Gender plays an important role in adolescent smoking behavior and smoking cessation. Further research is needed to understand how these differences may be incorporated into intervention design to increase cessation success rates among this vulnerable population of smokers.
doi:10.1016/j.addbeh.2012.02.007
PMCID: PMC3334461  PMID: 22405835
23.  Neural Activity During Health Messaging Predicts Reductions in Smoking Above and Beyond Self-Report 
Objective
The current study tested whether neural activity in response to messages designed to help smokers quit could predict smoking reduction, above and beyond self-report.
Design
Using neural activity in an a priori region of interest (a subregion of medial prefrontal cortex [MPFC]), in response to ads designed to help smokers quit smoking, we prospectively predicted reductions in smoking in a community sample of smokers (N = 28) who were attempting to quit smoking. Smoking was assessed via expired carbon monoxide (CO; a biological measure of recent smoking) at baseline and 1 month following exposure to professionally developed quitting ads.
Results
A positive relationship was observed between activity in the MPFC region of interest and successful quitting (increased activity in MPFC was associated with a greater decrease in expired CO). The addition of neural activity to a model predicting changes in CO from self-reported intentions, self-efficacy, and ability to relate to the messages significantly improved model fit, doubling the variance explained ( Rself−report2=.15,Rself−report+neuralactivity2=.35,Rchange2=.20).
Conclusion: Neural activity is a useful complement to existing self-report measures. In this investigation, we extend prior work predicting behavior change based on neural activity in response to persuasive media to an important health domain and discuss potential psychological interpretations of the brain–behavior link. Our results support a novel use of neuroimaging technology for understanding the psychology of behavior change and facilitating health promotion.
doi:10.1037/a0022259
PMCID: PMC3059382  PMID: 21261410
functional magnetic resonance imaging (fMRI); neuroimaging; behavior change; smoking
24.  Adolescent definitions of change in smoking behavior: An investigation 
Although adolescent smoking cessation has received increased research attention, little information exists as to how adolescents define change efforts for smoking behaviors. This issue is of particular importance because surveys routinely incorporate items assessing smoking cessation, yet how adolescents interpret such items is unclear. The present study investigated definitions of smoking behavior change efforts among adolescents. A total of 94 adolescent smokers—of average age 16.7 years (SD=1.0), 56% female, and 71% White—were asked to define the terms quit, stop, and cut down smoking. Responses to the three questions were categorized using content analysis. Definitions of quit and stop were categorized as (a) stop permanently, (b) stop temporarily, (c) stop except in certain situations, and (d) reduce smoking (for quit only). Definitions of cut down were categorized as (a) reduce the number of cigarettes, (b) smoke less in a time frame, (c) reduce smoking occasions, and (d) smoke less. Three trained raters sorted responses into each of the categories. Definitions of quit and stop were most frequently categorized in the stop permanently category (86% and 75%, respectively). Definitions of cut down were distributed across categories, with 51% categorized as smoke less, 25% smoking less in a time frame, and 25% reducing number of cigarettes. Different definitions of stop were related to smoking history and motivation to quit, although the other two terms were not related to adolescent individual characteristics. Findings highlight the importance of using clearly defined questionnaire items when assessing adolescent smoking change efforts.
doi:10.1080/14622200600910827
PMCID: PMC1855291  PMID: 17008195
25.  Patterns of cognitive dissonance-reducing beliefs among smokers: a longitudinal analysis from the International Tobacco Control (ITC) Four Country Survey 
Tobacco control  2012;22(1):52-58.
Objective
The purpose of this paper is to assess whether smokers adjust their beliefs in a pattern that is consistent with Cognitive Dissonance Theory. This is accomplished by examining the longitudinal pattern of belief change among smokers as their smoking behaviours change.
Methods
A telephone survey was conducted of nationally representative samples of adult smokers from Canada, the USA, the UK and Australia from the International Tobacco Control Four Country Survey. Smokers were followed across three waves (October 2002 to December 2004), during which they were asked to report on their smoking-related beliefs and their quitting behaviour.
Findings
Smokers with no history of quitting across the three waves exhibited the highest levels of rationalisations for smoking. When smokers quit smoking, they reported having fewer rationalisations for smoking compared with when they had previously been smoking. However, among those who attempted to quit but then relapsed, there was once again a renewed tendency to rationalise their smoking. This rebound in the use of rationalisations was higher for functional beliefs than for risk-minimising beliefs, as predicted by social psychological theory.
Conclusions
Smokers are motivated to rationalise their behaviour through the endorsement of more positive beliefs about smoking, and these beliefs change systematically with changes in smoking status. More work is needed to determine if this cognitive dissonance-reducing function has an inhibiting effect on any subsequent intentions to quit.
doi:10.1136/tobaccocontrol-2011-050139
PMCID: PMC4009366  PMID: 22218426

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